Integrative medicine and health in undergraduate and postgraduate medical education

Background and objective: Integrative Medicine and Health (IMH) is a theory-based paradigm shift for health, disease and health care, which can probably only be achieved by supplementing medical roles and competences. Definition of IMH: The definitions of the Academic Consortium for Integrative Medicine and Health 2015 and the so-called Berlin Agreement: Self-Responsibility and Social Action in Practicing and Fostering Integrative Medicine and Health Globally are used. The basic features of evidence-based Integrative Medicine and Health (EB-IMH) are based on the recommendations on EBM by David L. Sackett. Global State of Undergraduate and Postgraduate Medical Education (UG-PGME) for IMH: The USA and Canada are most advanced in the development of IMH regarding practice, teaching and research worldwide. Despite socio-cultural peculiarities, they can provide guidance for Europe and especially for Germany. Of interest here are competences for UG-PGME in IMH in primary care and in some specialist disciplines (e.g. internal medicine, gynecology, pediatrics, geriatrics, oncology, palliative care). For these specialties, the need for an interprofessional UG-PGME for IMH was shown in the early stages of development. UG-PGME for IMH in Germany: In the course of the development of the new Medical Licensure Act in Germany (ÄApprO), based on a revision of the National Competence-based Catalogue of Learning Objectives for Medicine (NKLM 2.0) and new regulations for Postgraduate Medical Education in Germany, suggestions for an extension of UG-PGME are particularly topical. To some extent there are already approaches to IMH. Old and new regulations are set out and are partly compared. As a result, some essential elements of IMH are mapped in the new ÄApprO. The new regulations for Postgraduate Medical Education do not mention IMH. Conclusion: The development of medical competences for IMH in the continuum of the UG-PGME could be supported by the coordinated introduction of appropriate entrustable professional activities (EPA) and IMH sub-competences combined with appropriate assessment.

1. Discuss how personal, cultural, ethnic, and spiritual beliefs shape an individual's interpretation and experience of his or her disease and its treatment. 2. Identify the major strengths and limitations of biomedical knowledge as applied to health care delivery. 3. Give examples of the different ways of knowing about illness and healing. 4. Discuss the distinction between the terms "healing" and "curing." 5. Describe the distinction between integrative medicine (IM) and CAM. 6. Describe the evidence for mind-body-spirit relationships in illness and health. 7. Describe the prevalence and patterns of CAM use in the patient's community. 8. Describe the basic concepts of the most commonly used CAM modalities such as chiropractic, herbal and nutritional medicine, and mind-body therapies, and of one or more of the widely used traditional systems of medicine such as Chinese medicine and Ayurvedic medicine, including: a. Basic definitions/theory/philosophy/history b. Common clinical applications c. Potential for adverse effects d. Current research evidence for efficacy e. Reputable resources for in-depth information f. Training/credentialing standards for practitioners 9. Identify potential legal and ethical implications related to the inclusion or the exclusion of CAM modalities in a patient's treatment plan. 10. Identify reputable information resources for CAM and IM in order to support life-long learning. 11. Explain the current status of government regulation of herbal medicines and dietary supplements.
Attitudes A graduating physician shall be able to demonstrate: 1. A respect for the influence of the patient's personal, cultural, ethnic, and spiritual beliefs on their experience of health and illness and on the patient's clinical decision-making process 2. An awareness of how the physician's own personal, cultural, ethnic, and spiritual beliefs may affect their choice of recommendations regarding patients' treatment decisions. 3. A respect for the strengths and limitations of applying evidence-based medicine principles to the circumstances of an individual patient. 4. A respect for the potential of a variety of healing approaches to be effective for the treatment of certain conditions. 5. An awareness of the importance of self-care both for physician well-being and as a model to promote selfcare in patients.

Skills
A graduating physician shall be able to: 1. Demonstrate an ability to assist patients in developing their own self-care program as part of encouraging active patient involvement in health promotion and clinical decision making. 2. Demonstrate skills to communicate effectively with patients about all aspects of their health and illness including biological, psychological, social, and spiritual as part of comprehensive history taking. 3. Demonstrate skills to communicate effectively: a. with patients about their use of CAM in a respectful and culturally appropriate manner; and b. with patients and all members of the interdisciplinary health care team in a collaborative manner to facilitate quality patient care. (The team may include nurses, chaplains, nutritionists, social workers, practitioners of healing systems other than allopathic medicine such as Chinese medicine or chiropractic, etc.) 4. Design a personal self-care program that includes: a. Learning to assess one's level of stress b. Implementing a self-care strategy (may include nutrition awareness, self-regulatory techniques, exercise, journaling, creative arts, spirituality, mind-body skills, etc.) 5. Demonstrate an ability to utilize the principles of evidence-based medicine in analyzing integrative medicine approaches, including: a. developing focused questions regarding the application of IM principles or practices for an individual patient; b. utilizing databases, peer-reviewed publications, authoritative textbooks, Web-based resources, experiential knowledge of CAM practitioners, and participatory observation to gather relevant information; c. evaluating the information for scientific quality and clinical relevance; d. formulating a plan to implement findings in care of an individual patient; and e. evaluating the outcome of applying IM principles or practices in patient care.

TEACHING AND ASSESSMENT METHODS
Given the divergent nature of CAM therapies and the varying levels of evidence that support their use, the integration of these topics into conventional medical education poses a unique challenge. Innovative educational approaches are required to achieve an effective understanding of the principles and practice of integrative medicine. These approaches demand that educators in this area of medicine develop methods beyond those needed to teach new scientific facts. Three key components for effective implementation of teaching in integrative medicine that are not typically part of medical school curricula at medical schools are  experiential approaches to facilitate an understanding of complementary and alternative therapies;  education of medical students in self-care and reflection; and  faculty development programs to produce educators who have both knowledge and skills in integrative medicine and recognize the importance of self-care and reflection in medical education and practice.   1. Practice patient-centered and relationship-based care.
2. Obtain a comprehensive health history which includes mind-body-spirit, nutrition, and the use of conventional, complementary and integrative therapies and disciplines. 3. Collaborate with individuals and families to develop a personalized plan of care to promote health and well-being which incorporates integrative approaches including lifestyle counselling and the use of mind-body strategies. 4. Demonstrate skills in utilizing the evidence as it pertains to integrative healthcare. 5. Demonstrate knowledge about the major conventional, complementary and integrative health professions. 6. Facilitate behavior change in individuals, families and communities. 7. Work effectively as a member of an interprofessional team. 8. Engage in personal behaviors and self-care practices that promote optimal health and wellbeing. 9. Incorporate integrative health care into community settings and into the health care system at large. 10. Incorporate ethical standards of practice into all interactions with individuals, organizations and communities. ID=identification number; B=Basics; BC= (medical) basic competence; PY=PY competence (for elective clerkship, 6 th year of UGME curriculum); GP=PGME entrance competence; SC=Science competence.
According to the theoretical understanding used here, competence cannot be equated with practical skills or abilities alone. Achieving competence for action (competence levels 3a or 3b) requires the acquisition of factual knowledge (competence level 1) or knowledge about action and justification (competence level 2). The taxonomy used here to describe the levels of competence has been developed in an international context.
The numbers 2, 3a and 3b refer to the levels of competence to be achieved, which build on each other: 2. Knowledge of practice and justification: explain facts and contexts, integrate them into the clinical-scientific context and evaluate them based on data.

Competence for practice:
3a. perform and demonstrate personally under guidance. 3b. carry out independently and appropriately in the knowledge of the consequences.
Level 1. (factual knowledge: name and describe descriptive knowledge (facts).) does not appear here, because the factual knowledge for chapter 16 or sub-chapter 16.9 is defined in other chapters.
Explanation on the meaning of the identification numbers in the NKLM: Within the sub-chapters, a three-stage, hierarchical structure was used:  Level 1: Competences  Level 2: Sub-competences  Level 3: Learning objectives with indication of competence levels Levels 1 and 2 are recommended. Level 3 is intended to be used by the medical faculties to be tested and critically evaluated.
The identification number (ID) of the (sub-) competences and learning objectives provides information about the sub-chapter and the respective level of detail. The first digit indicates the respective sub-chapter. The number of the following digits refers to the level of classification.